No-Test Medication Abortion: A Systematic Review

Early medical abortion before missed menses: a prospective observational study of outcomes of abortion at less than 30 days from last menstrual period

INTRODUCTION

High-sensitivity urine pregnancy tests can detect pregnancy before missed menses. The widespread availability of these tests, alongside improvements in abortion access in many settings, may mean more women present for abortion at a very early stage of pregnancy. We aimed to examine the outcome of early medical abortion (EMA) in pregnancies less than 30 days from last menstrual period (LMP).

METHODS

This study analysed prospectively collected data on patients at less than 30 days from LMP seeking abortion at a single service in Edinburgh, UK between March 2020 and December 2023. We determined the effectiveness, outcomes of the pregnancy (complete abortion, ongoing pregnancy, incomplete abortion) and serious complications among those seeking EMA at this gestation.

RESULTS

Of 13 565 patients seeking abortion, 78 (0.6%) presented with a self-reported positive home pregnancy test and less than 30 days from LMP. Some 63/78 patients (81%) proceeded to EMA with mifepristone followed by misoprostol. Of this group, 31/63 (49%) had a pre-abortion ultrasound. Complete abortion occurred in 58/63 (92%, 95% CI 82% to 97%), 4/63 (6%) had an ongoing pregnancy and 1 (1%) had a surgical evacuation for incomplete abortion. There were no serious complications.

CONCLUSIONS

Only a very small percentage of patients present for abortion before a missed period. Nevertheless, EMA at this stage is safe and effective. There may be a higher rate of ongoing pregnancy, and so those patients wishing to proceed to EMA should be advised of the importance of confirming success in line with local protocols.

Accuracy of survey-based assessment of eligibility for medication abortion compared with clinician assessment

BACKGROUND

With increasingly restricted access to facility-based abortion in the United States, pregnant people are increasingly relying on models of care that use history-based or no-test approaches for eligibility assessment. Minimal research has examined the accuracy of abortion patients' self-assessment of eligibility for medication abortion using their health history. This step is necessary for ensuring optimal access to history-based or no-test models, as well as potential over-the-counter access.

OBJECTIVE

This study aimed to examine the accuracy of pregnant people's eligibility for medication abortion as determined using their self-reported health history, compared with clinician assessments using ultrasound and other tests.

STUDY DESIGN

In this diagnostic accuracy study, we recruited people seeking medication or procedural abortion from 9 abortion facilities, aged ≥15 years, English- or Spanish-speaking, and with no prior ultrasound conducted at the recruitment facility. Before ultrasound, we surveyed participants on medication abortion eligibility, including estimated gestational duration, medical history, contraindications, and ectopic pregnancy risk factors such as pain and bleeding symptoms. We compared patients' eligibility based on self-reported history with subsequent clinician assessment, focusing on overall diagnostic accuracy, or area under the receiver operating characteristic curve, sensitivity, specificity, and proportion with discordant patient and clinician eligibility assessment, using 77 days as the upper gestational duration limit.

RESULTS

Overall, 22.1% of 1386 participants were ineligible for medication abortion according to clinician assessment. Overall diagnostic accuracy of self-assessment was acceptable (area under the receiver operating characteristic curve=0.65; 95% confidence interval, 0.63-0.67), with sensitivity of 92.2% (88.6-94.9) and specificity of 37.8% (34.9-40.7). Very few participants (n=24; 1.7%) self-assessed as eligible when the clinician deemed them ineligible; many more (n=672; 48.5%) self-assessed as ineligible when the clinician deemed them eligible. The most common patient-reported contraindications included unexplained pain (55.5%), gestational duration >77 days (36.5%), and anemia (29.0%). On its own, unexplained pain had poor sensitivity in identifying those with clinician concern for ectopic pregnancy (41.7%; 95% confidence interval, 15.2-72.3). Removing unexplained pain as a screening criterion resulted in higher accuracy (0.71; 95% confidence interval, 0.69-0.74) (P<.001).

CONCLUSION

History-based screening protocols are highly effective at ensuring that few people receive medication abortion when ineligible. However, a sizable group screens as ineligible when they are in fact eligible, suggesting a need for more specific screening questions.

Self-performed Rh typing: a cross-sectional study

OBJECTIVE

To evaluate whether patients are capable and willing to self-administer and interpret an EldonCard test to determine their Rh status.

METHODS

This was a cross-sectional study in Honolulu, HI, USA of pregnancy-capable people aged 14-50 years who did not know their blood type and had never used an EldonCard. Participants independently completed EldonCard testing, determined their Rh type and answered a survey on feasibility and acceptability. Separately, a blinded clinician recorded their interpretation of the participant's EldonCard. When available, we obtained blood type from the electronic health record (EHR). We measured Rh type agreement between participant, clinician and EHR, as well as participant comfort and acceptability of testing.

RESULTS

Of the 330 total participants, 288 (87.3%) completed testing. Patients and clinicians had 94.0% agreement in their interpretation of the EldonCard for Rh status. Patient interpretation had 83.5% agreement with EHR while clinician and EHR had 92.3% agreement. Sensitivity of EldonCard interpretation by patient and clinician was 100%. Specificity was 83.2% for patients and 92.2% for clinicians. Two patients (of 117) had Rh-negative blood type in the EHR. The vast majority of participants found the EldonCard testing easy (94.4%) and felt comfortable doing the testing (93.7%). Participants with lower education levels felt less confident (p=0.003) and less comfortable with testing (p=0.038); however, their ability to interpret results was similar to others (p=0.051).

CONCLUSIONS

Patient-performed Rh typing via the EldonCard is an effective and acceptable option for patients, and could be used as a primary screening test for Rh status.

Test or No-Test: Comparison of Medication Abortion Outcomes and Adverse Events When Forgoing Ultrasound, Laboratory Testing, and Physical Examination

OBJECTIVES

This study aimed to compare demographics and clinical outcomes between patients who did not undergo investigations and those who underwent investigations before receiving a prescription for medication abortion (MA) during the first 6 months of the COVID-19 pandemic. Outcomes include success rates, adverse events, pathways to completion, and loss to follow-up rates.

METHODS

We conducted a retrospective medical record review of 1452 patients presenting for MA between 23 March 2020 and 30 September 2020. Descriptive statistics, 2 × 2 chi-square tests, and Fisher exact tests were used to compare characteristics and outcomes between groups.

RESULTS

Of the 1307 patients who received a prescription, 895 (68.5%) were in the no-test group and 412 (31.5%) were in the test group. The success rate was 95.2%, with no significant difference between groups (94.0% and 95.8%, P = 0.194). Rates of adverse events were low, with 28 patients presenting for emergency department visits (2.1%), 62 having clinically significant retained products of conception (4.7%), 5 with heavy bleeding requiring treatment (0.4%), 16 with ongoing pregnancy (1.2%), and 3 requiring ectopic pregnancy management (0.2%). Completion of abortion was verified in 1034 patients (80.5%), and the loss to follow-up rate was 22.6%, with no difference between the groups (82.1% vs. 79.8%, P = 0.341; and 21.4% vs. 23.1%, P = 0.477; respectively).

CONCLUSIONS

We found that clinical outcomes were consistent across the 2 groups, with high success rates and low adverse event rates. Our study contributes to the growing body of evidence that allows for individualized care implementing selective use of low- and no-test MA protocols.

Clinical and service delivery outcomes following medication abortion provided with or without pretreatment ultrasound or pelvic examination: An updated comparative analysis

OBJECTIVES

This study aimed to compare medication abortion outcomes among people screened without or with ultrasound or pelvic examination.

STUDY DESIGN

We used data collected from March 24, 2020, to September 27, 2021, at five TelAbortion Project sites that provided medication abortion with mifepristone and misoprostol by mail. Using logistic regression weighted on propensity scores, we compared outcomes in participants who had neither ultrasound nor examination before treatment (No-Test group) or had such tests (Test group). We analyzed outcomes separately for participants screened early in the analysis period (before September 15, 2020) or later. Outcomes included procedural abortion completion or ongoing pregnancy, serious adverse events, and unplanned posttreatment abortion-related clinical visits.

RESULTS

Among 416 participants in the early period, the No-Test group had a significantly higher risk than the Test group of procedural abortion completion or ongoing pregnancy (5.6% vs 0.9%, risk difference 4.6%, 95% CI 1.5%, 7.7%) and abortion-related clinical visits (13.3% vs 6.3%; risk difference 7.0%; 95% CI 1.1%, 12.8%). Among 364 participants screened later, the risk of procedural abortion completion or ongoing pregnancy did not differ by group, while unplanned abortion-related clinical visits were less common in the No-Test group (9.9% vs 20.5%; risk difference -10.6%; 95% CI -20.1%, -1.1%). The risk of serious adverse events did not differ by group in either period.

CONCLUSIONS

When providers first began omitting ultrasound or pelvic examination before medication abortion, the practice was associated with increased risks of failure of complete abortion and posttreatment clinical visits; however, these increased risks resolved over time.

IMPLICATIONS

Medication abortion without pretreatment ultrasound or examination is effective and safe. This model should be routinely offered to eligible patients.

Home use of mifepristone for medical abortion: a systematic review

BACKGROUND

In many countries, persons seeking medical abortion with mifepristone followed by misoprostol can self-administer the second drug, misoprostol, at home, but self-administration of the first drug, mifepristone, is not allowed to the same extent.

OBJECTIVES

This systematic review aims to evaluate whether the efficacy, safety and women's satisfaction with abortion treatment are affected when mifepristone is self-administered at home instead of in a clinic.

SEARCH STRATEGY

A literature search covered CINAHL, Cochrane Library, Embase, Ovid MEDLINE and APA PsycInfo in October 2022.

SELECTION CRITERIA

Eligible studies focused on persons undergoing medical abortion comparing home and in-clinic mifepristone intake. Outcomes included abortion effectiveness, compliance, acceptability, and practical consequences for women.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed eligibility and risk of bias. Meta-analysis included similar studies while those differing in design were synthesised without meta-analysis.

RESULTS

Six studies (54 233 women) of medical abortions up to 10 weeks were included. One randomised controlled trial and one retrospective register study had moderate risk of bias, and four non-randomised clinical trials where women could choose the place for intake of mifepristone had serious risk of bias. There was no difference in abortion effectiveness (high confidence) or compliance (moderate confidence) between mifepristone administered at home or in-clinic. No differences in complications were detected between groups and most women who chose home administration of mifepristone expressed a preference for this approach.

CONCLUSIONS

Our systematic review demonstrates that the effectiveness of medical abortion is comparable regardless of mifepristone administration and intake, at home or in the clinic.

No test medical abortion - a review of the evidence on selective use of preabortion testing

PURPOSE OF REVIEW

The last decade has seen a cascade of different telemedicine models for medical abortion (MA) being tested and implemented. Among these service delivery models is the 'no-test' MA model, in which care is provided remotely and eligibility for the MA is based on history alone. The purpose of this review is to provide an overview of the existing evidence for no-test MA.

RECENT FINDINGS

The evidence base for no-test MA relies heavily on cohort and noncomparative studies predominantly from high resource settings. Recent findings indicate that no-test MA is safe, effective, and highly acceptable. Diagnoses of ectopic pregnancy and underestimation of gestational age were rare. Identified advantages included shortening time to access MA and mitigating access barriers such as cost, and geographical barriers. Abortion seekers valued omitting the ultrasound citing reasons such as privacy concerns, costs, more flexibility, and control. The impacts of no-test MA on unscheduled postabortion contacts and visits and on contraceptive use were unclear due to limited evidence.

SUMMARY

No-test MA can be provided to complement other care pathways including those with some or no in-person care. Further research is needed to allow for widespread adoption of no-test MA and scale-up in a variety of contexts, including low-resource settings.

Self-Determination of Eligibility for Medication Abortion Without Ultrasonography Using a History-Based Tool: LMP-SURE

OBJECTIVE

To evaluate a self-screening eligibility tool for medication abortion without an ultrasonogram.

METHODS

We designed a patient-administered, five-question screening tool (LMP-SURE) that assesses gestational age plus factors associated with misdating or ectopic pregnancy. We recruited participants without prior ultrasonograms from family planning clinics in Alaska, Hawai'i, Idaho, and Utah to complete a brief survey including LMP-SURE and then obtained ultrasound dating by chart review. We compared eligibility for medication abortion by ultrasonogram with eligibility by the LMP-SURE screening tool.

RESULTS

We consented 1,026 participants; 781 met eligibility requirements and completed the tool. Using the LMP-SURE tool, we identified 493 participants (65.1%) eligible for medication abortion without an ultrasonogram. The LMP-SURE tool sensitivity (ability to correctly identify a patient ineligible for medication abortion) was 83.8% (95% CI, 73.1-90.8), specificity (ability to correctly identify a patient eligible for medication abortion) was 70.0% (95% CI, 66.4-73.3), likelihood ratio (-) (probability of someone eligible by LMP-SURE to be ineligible by ultrasonogram vs eligible by ultrasonogram) was 0.23 (95% CI, 0.13-0.40), and percentage of false-negatives was 1.5%. Only 11 patients (1.5%) who met eligibility for medication abortion without an ultrasonogram by the LMP-SURE tool were found ineligible for medication abortion by their ultrasonogram. Of those with conflicts, six (0.8%) had a gestational age beyond 77 days. The two participants (0.3%) diagnosed with ectopic pregnancies both required ultrasonograms by LMP-SURE.

CONCLUSION

This patient-facing, brief, history-based screening tool can safely minimize the need for ultrasonogram before medication abortion.

Abortion

Induced abortion is safe, is common, and reduces pregnancy-related maternal morbidity and mortality. Internal medicine physicians are uniquely positioned to counsel patients on their pregnancy options, assess medical risks of pregnancy in the context of comorbidities, refer for abortion care when the patient desires it, or provide abortion care themselves. Clinicians can also provide anticipatory guidance about what patients should expect if they seek abortion care.

An assessment of clinical outcomes of medication abortion without pretreatment ultrasonography in Planned Parenthood, United States, 2020-2021

OBJECTIVES

Routine ultrasound before medication abortion (MAB) may create an impediment to expanding abortion access. This study examines clinical outcomes of MAB without pretreatment ultrasound evaluation at Planned Parenthood health centers in multiple states.

STUDY DESIGN

We conducted a secondary analysis of data from 23 US-based Planned Parenthood affiliates that provided MAB without pretreatment ultrasound for eligible patients from March 2020 to December 2021. Affiliates aggregated electronic health record data from MABs at ≤77 days gestation (based on self-report of last menstrual period) without a pretreatment ultrasound (N = 18,041). Among MABs with known outcomes (N = 9821), we calculated the incidence rates and 95% confidence intervals (CI) for completed abortion, ongoing pregnancy, subsequent procedure, emergency department/hospital visits associated with MAB, ectopic pregnancies, and gestational duration greater than 77 days.

RESULTS

Among MABs with known outcomes, 96.3% had a complete abortion (95% CI = 95.9%-96.7%), and 2.0% had an ongoing pregnancy (95% CI = 1.7%-2.3%). Four percent had a subsequent procedure (95% CI = 3.6%-4.4%), and 2.3% had a documented emergency department/hospital visit (95% CI = 2.0%-2.6%). Less than 1% had a confirmed ectopic pregnancy (0.15%, 95% CI = 0.09%-0.25%) and had a gestational duration later identified to be greater than 77 days (0.13%, 95% CI = 0.05%-0.29%).

CONCLUSIONS

Our calculated incidence rates of clinical outcomes align with rates from the previous literature on MAB and from the emerging literature on MAB without pretreatment ultrasonography. Findings from this analysis suggest that MAB without pretreatment ultrasound is safe and effective for eligible patients.

IMPLICATIONS

This large US study found that medication abortion without pretreatment ultrasonography results in similar clinical outcomes to prepandemic models that include pretreatment ultrasonography. Medication abortion without a pretreatment ultrasound may be adopted by abortion providers seeking to expand options for their patients as access to abortion continues to erode.

The Safety and Efficacy of a "No Touch" Abortion Program Implemented in the Greater Toronto Area During the COVID-19 Pandemic

OBJECTIVES

To evaluate the safety and efficacy of first-trimester "No Touch" medication abortion programs at 2 clinics in Toronto, Ontario during their early implementation in response to the COVID-19 pandemic.

METHODS

This retrospective study included all patients who underwent virtual consultation for mifepristone-misoprostol medication abortion between April 2020-August 2022 at 2 reproductive health clinics. In response to the pandemic, "No Touch" abortion protocols have been developed that align with the Canadian Protocol for the Provision of Medical Abortion via Telemedicine. Records were reviewed for demographic information, clinical course, investigations required, confirmation of complete abortion and adverse events. The primary outcome was complete medication abortion, defined as expulsion of the pregnancy without requiring uterine aspiration.

RESULTS

A total of 277 patients had abortions initiated in the "No Touch" or "Low Touch" care pathways and had sufficient follow-up to determine outcomes. Of these patients, 92.8% (95% CI 89.7%-95.8%) had a complete medication abortion (n = 257) and 76.1% (n = 159) remained "No Touch" throughout their care. Investigations were performed for 102 participants before or after their abortion, classifying them as "Low Touch". Nineteen patients (6.9%) underwent uterine aspiration. The rate of adverse events was low, with 1 case of a missed ectopic pregnancy and 1 patient requiring hospitalization for endometritis.

CONCLUSIONS

"No Touch" provision of mifepristone-misoprostol medication abortion care was safe and effective with outcomes comparable to previous studies. These results provide evidence for the efficacy and safety of a "No Touch" approach in the Canadian context, which has the potential to reduce barriers to accessing abortion care.

Understanding medication abortion ineligibility due to gestational age among a cohort of patients in Southern California

OBJECTIVE

Medication abortion (MAB) is safe and effective up to 77 days gestation. Limited data are available on how often patients are ineligible for MAB due to advanced gestational age and how many of those ineligible go on to receive procedural abortion.

STUDY DESIGN

Retrospective analysis of electronic health records from Planned Parenthood of the Pacific Southwest (PPPSW) from January - December 2021. PPPSW has four procedural abortion sites and 15 MAB-only clinics that offered appointments only if last menstrual period-based GA was ≤70 days or unknown. Patients >70 days gestation by intake ultrasound at a MAB-only clinic were referred to a procedural center.

RESULTS

Of 11,684 patients presenting for MAB at MAB-only sites 2224 (19%) did not receive a MAB; 3.8% (N = 444) presented past 70 days gestation and were thus ineligible due to gestational age limits. Of those ineligible (N = 444), 234 (53%) measured between 71-77 days of gestation. Three quarters (75.7%) of those ineligible went on to receive a procedural abortion at PPPSW after a mean wait time of 10 days. In multivariable analysis, no demographic factors were associated with higher odds of receiving a procedural abortion.

CONCLUSIONS

Presenting for MAB past a gestational age limit was uncommon, supporting safety of no-test MAB protocols. A quarter of people ineligible for MAB due to gestational age did not receive a procedural abortion at PPPSW. If MAB were offered up to 77 days, half of patients who were denied MAB due to gestational age could have received MAB, expanding patient access.

IMPLICATIONS

Being ineligible for MAB due to advanced gestational age was uncommon. Increasing MAB gestational age limits from 70 days to 77 days could further improve abortion access.

Telemedicine Abortion

Telemedicine has become a substantial part of abortion care in recent years. In this review, we discuss the history and regulatory landscape of telemedicine for medication abortion in the United States, different models of care for telemedicine, and the safety and effectiveness of medication abortion via telemedicine, including using history-based screening protocols for medication abortion without ultrasound. We also explore the acceptability of telemedicine for patients and their perspectives on its benefits, as well as the use of telemedicine for other parts of abortion care. Telemedicine has expanded access to abortion for many, although there remain limitations to its implementation.

The evolving role of emergency medicine in family planning services

PURPOSE OF REVIEW

The emergency department serves as an essential access point for a variety of healthcare services. This review will examine the recent expansion of family planning and reproductive health services in the emergency department.

RECENT FINDINGS

An increasing number of patients present to emergency departments for early pregnancy loss (EPL), abortion care, and contraceptive management. Availability of comprehensive EPL management varies dramatically, possibly due to lack of provider knowledge or training. Particularly in remote settings, educational interventions - such as providing information about medication management and training in uterine aspiration - may standardize this management. Restrictive abortion laws raise concerns for changing and increased patient presentations to the emergency department for complications related to unsafe or self-managed abortion. Emergency medicine providers should anticipate that more patients will present without a prior ultrasound confirming intrauterine pregnancy prior to initiating no-touch or self-managed abortions. Particularly among pediatric patients, there may be a role for contraceptive counseling during an emergency department visit. Novel strategies, including web-based interventions and emergency department-based curricula for contraceptive counseling, may help reach those who otherwise may not seek reproductive healthcare in a clinic setting.

SUMMARY

The intersection of emergency medicine and reproductive healthcare is a promising frontier for providing immediate, patient-centered, family planning care. Continued research and provider education are necessary to refine these approaches, address disparities, and respond to the changing reproductive healthcare landscape.

Approved but Unavailable: A Mystery-Caller Survey of Mifepristone Access in a Large Ontario City

OBJECTIVES

Mifepristone/misoprostol (mife/miso) has been approved in Canada since 2017, and is available since 2018. Mife/miso does not require witnessed administration in Canada, and therefore most patients obtain a prescription for home use. We sought to determine the proportion of pharmacies in Hamilton, Ontario, Canada, a city of over 500 000, that had combination mife/miso in stock at any given time.

METHODS

A mystery-caller approach was used to survey all pharmacies (n = 218) in Hamilton, Ontario, Canada between June 2022 and September 2022.

RESULTS

Of the 208 pharmacies that were successfully contacted, only 13 (6%) pharmacies had mife/miso in stock. The most commonly cited reasons for the medication being unavailable were low patient demand (38%), cost (22%), lack of familiarity with medication (13%), supplier issues (9%), training requirements (8%), and medication expiry (7%).

CONCLUSIONS

These findings suggest that while mife/miso has been available in Canada since 2017, significant barriers remain to patients accessing this medication. This study clearly demonstrates a need for further advocacy and clinician education to ensure mife/miso is accessible to the patients who require it.

Remote Provision of Medication Abortion and Contraception Through Telemedicine

This Narrative Review describes the remote provision of family planning services, including medication abortion and contraception, through telemedicine. The coronavirus disease 2019 (COVID-19) pandemic was a catalyst to shift toward telemedicine to maintain and expand access to crucial reproductive health services when public health measures necessitated social distancing. There are legal and political considerations when providing medication abortion through telemedicine, along with unique challenges, even more so after the Dobbs decision starkly limited options for much of the country. This review includes the literature describing the logistics of telemedicine and modes of delivery for medication abortion and details special considerations for contraceptive counseling. Health care professionals should feel empowered to adopt telemedicine practices to provide family planning services to their patients.